Responsible to support the development and implementation of required activities to ensure compliance with Centers for Medicare and Medicaid Services (CMS) requirements and mandates, that ensures compliance with Medicare contracting and reporting requirements.
Coordinate operational activities with appropriate department personnel, establish work plans, target dates, conduct regular status meetings, report status, identify and escalate issues, recommend solutions, track and report to resolution. Develop and prepare HMSA's corrective action plans in response to audit or monitoring findings to meet performance standards. Serve as the department's representative/liaison on organizational projects/workgroups.
Exempt or Non-Exempt
- Bachelor's degree and three (3) years of related work experience; or equivalent combination of education and related work experience.
- Effective oral and written communication skills.
- Strong analytical and interpretive skills
- Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.
Duties and Responsibilities
a. Support the administration and management of the day to day operational activities needed to comply with CMS requirements and HMSA standards. Be knowledgeable on all CMS regulations and HMSA operational standards. This duty requires the analyst to:
- Ensure all HMSA's Medicare Program contractual obligations and requirements are met or exceeded in appropriate operational depts. Interpret CMS regulations and provide operational impact guidance to departments and HMSA's contracted vendors. Adjust existing systems, operations, and/or workflows to adapt to the ever-changing requirements of CMS and any identified deficiencies in current program quality and administration. Then monitor compliance via report and data validation.
- Monitor communications from CMS and determine if/how changes to operations are needed in applicable internal departments. Follow-up to ensure correct action was taken on a timely basis.
- Handle ad hoc questions and research issues, and provide assistance to departments to assess impact and determine best course of action.
b. Complete administrative reports based on business needs, program compliance, plan performance, and as assigned. Advise the manager on significant matters pertaining to regulatory and reporting requirements, program compliance, or needed program changes.
c. Resolve all member cases and ensure CMS timeliness and accuracy requirements are met. Conduct quality assurance and process improvement reviews to assess compliance and verify appropriate actions are taken. Monitor and track HMSA's compliance with CMS program standards, policies, and guidance through multiple sources, such as HMSA submitted reports to CMS, CMS generated performance metrics, and department self-reported issues.
d. Coordinate, develop and help implement Medicare Program policies and procedures to operationalize CMS requirements affecting multiple departments. Maintain understanding of Medicare program operations as it relates to marketing, membership enrollment, claims processing, financial statements, customer service, provider contracting, quality improvement, utilization management, etc.
e. Obtain policy clarifications/additional guidance, coordinate special administrative and operational requests, respond to CMS inquiries and requests for information, and coordinate CMS performance reviews. Participate in the development and implementation of required corrective action plans to address CMS audit and internal quality assurance review findings. Coordinate and monitor activities with appropriate department staff to ensure that corrective action plans are implemented timely and accurately
f. Performs all other miscellaneous responsibilities and duties as assigned or directed.
Job Type: Full-time